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Obtaining Insurance Benefits for Higher Levels of Care

Many of the issues discussed in the previous section will be relevant to treatment at any level of care, but more intensive treatment often brings up separate issues. Before an insurance company will cover eating disorder treatment, they will conduct a utilization review. A utilization review occurs when your insurance company reviews the insured’s benefits to make sure that the services being requested are both covered and “medically necessary.”

A utilization review generally consists of several steps:

Precertification – After completing a face-toface assessment with the patient, the assessing clinician will call the insurance company to request authorization of services before the patient begins treatment. The reviewers generally ask for the five-axis diagnoses, height, weight, recent behaviors, treatment history, goals for treatment, and estimated length of stay. A case manager (CM) is usually assigned to the case during this initial call, several days are usually authorized, and the next review is scheduled.

Concurrent Review – Several days are usually authorized at a time and the insurance companies request scheduled clinical updates in order to authorize additional days. These updates and requests for additional days are called concurrent reviews. They are usually done with the same care manager every time. The CM generally asks for the following information: current weight, vitals, lab/bloodwork results, behaviors/struggles, progress in treatment (individual work, family work, insight development, etc.), mood/ affect, participation/motivation, discharge plan, coordination with outpatient team, and estimated length of stay.

It is very important to explain this process to the patient as some patients may be overwhelmed when they initially hear that their insurance company has authorized 5 or 6 days and they plan to be in treatment for weeks or months.

Discharge Summary – Some insurance companies request notification of the patient’s discharge. The discharge summary usually includes the following information: Five-Axis diagnoses upon discharge (any changes?), medications upon discharge, follow-up appointments (names of providers, dates and times of appointments), total number of days used. This is usually a pretty quick call and it’s not always required by insurance.

Other steps:

“Clinical Case Consultation” – Occasionally reviewers need to consult with other clinicians or doctors before determining how many days they will authorize. This generally happens after the patient has been in treatment for a while, appears to meet the criteria for medical necessity, but may be getting close to requiring a “doc-to-doc” review. This is not a denial. After consulting with either the clinical team at the insurance company or with the treating doctor at the facility/clinic, the reviewer will call back with an authorization and usually a few additional questions for the next review.

“Doc-to-Doc” or “Peer-to-Peer” Review – Cases are usually sent for a “doc-to-doc” for one of the following reasons:

The patient has been in treatment for long enough that the reviewer is unable to authorize additional days without involving a doctor from the insurance company.

The patient does not clearly meet the criteria for medical necessity and a doctor must use his or her clinical expertise/ discretion to determine if the level of care being requested is warranted.

If this happens, it is fairly indicative of an upcoming denial within the next few reviews.

Although the insurance company may not always honor the request, it is perfectly acceptable (and recommended) to specifically request for the reviewer to be a doctor who specializes in eating disorders.

Appeal – If authorization is denied, a facility/ provider has the right to file an appeal and conduct a review with a different doctor.